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code among the top nine diagnoses and proce-dures would certainly help. However, thelarger issuedestablishing agreement acrossthe field about what palliative care representsand the circumstances in which the V66.7code is appropriatedis critical to understand-ing when end-of-life care is being provided.We also suggest that CMS consider adding anindicator to the MedPAR data set that flagspatients who have received the MedicareHospice Benefit in the past 12 months.

Disclosures and AcknowledgmentsThe authors were not supported by grants or

other financial support for this manuscript.They declare no conflicts of interest.

doi:10.1016/j.jpainsymman.2010.09.010

Address correspondence to: Kristin Reed, MPH, HealthGrades, Inc., 500 Golden Ridge Road, Suite 100,Golden, CO 80401, USA. E-mail:healthgrades.com

Accepted for publication: September 30, 2010.

References1. Lilford R, Pronovost P. Using hospital mortalityrates to judge hospital performance: a bad ideathat just won’t go away. BMJ 2010;340:c2016.

2. Iezzoni LI, Ash AS, Coffman GA, Moskowitz MA.Predicting in-hospital mortality: a comparison of se-verity measurement approaches. Med Care 1992;30:347e359.

3. De Marco MF, Lorenzoni L, Addari P, Nante N.Evaluation of the capacity of the APR-DRG classifica-tion system to predict hospital mortality. EpidemiolPrev 2002;26:183e190.

4. Murphy J, McFarlane E, Olmsted MG, et al. RTI In-ternational. U.S. News & World Report ‘‘BestHospitals’’ 2010-11 methodology. 2010. Available fromhttp://static.usnews.com/documents/health/best-hospitals-methodology.pdf. Accessed August 15,2010.

5. Jarman B, Bottle A, Aylin P, Brown M. Dr. Foster’scase notes: monitoring changes in hospital standar-dised mortality ratios. BMJ 2005;330:329.

6. Centers for Medicare & Medicaid Services.Medicare Provider Analysis and Review (MedPAR)file. 2010. Available from http://www.cms.gov/IdentifiableDataFiles/05_MedicareProviderAnalysisandReviewFile.asp. Accessed August 15, 2010.

7. World Health Organization. WHO definition ofpalliative care. 2010. Available from http://www.who.int/cancer/palliative/definition/en/.AccessedAugust15, 2010.

8. American Academy of Hospice and PalliativeMedicine. Position statement on access to palliativecare and hospice. March 11, 2008. Available fromhttp://www.aahpm.org/positions/default/access.html.Accessed August 15, 2010.

Analyzing HospitalMortality Ratesand Palliative CareKristin Reed, MPHHealth Grades, Inc., Golden, Colorado, USA

In their article ‘‘Hospital Mortality Rates andPalliative Care,’’ Cassel et al. do a thorough joboutlining many of the challenges associatedwith analyzing hospital mortality rates. In par-ticular, they point out the challenge of risk ad-justing for patients at the end of life and theinability to separate the goals of care from theoutcome of care using publicly available datasources. One of the goals outlined in the re-search is to educate health care administratorsabout the potential punitive impact of palliativecare on mortality ratings. Based on the lack ofa standardized methodological approach usedby the different ratings entities and limitationsof the data, the authors outline several potentialsolutions to addressing endof life inpublicmor-tality ratings.One potential solution offered is to simply do

away with hospital mortality rate measures.Some have suggested that hospital mortalitymeasures do not adequately distinguish pre-ventable deaths from expected deaths, andtherefore, process is a potentially better mea-sure of quality.1 I would argue that mortalitymeasures capture what process measures missand that both are necessary to close the gap be-tween best practice and actual care. Processmeasures, while evidence based and appropri-ate, do not always correlate with short-termoutcomes.2 Therefore, a hospital can have100% compliance with all mandated processmeasures but still have poor outcomes. In theend, if process is not improving the outcome,then it is time to reevaluate the process. Only

kreed@

Vol. 40 No. 6 December 2010 929Commentaries

by measuring outcomes can the gap even beidentified to begin with.

It is also important to remember that theaudience for comparative health care qualityinformation is patients and their families.When patients come to the hospital, they ex-pect that they are receiving evidence-basedmedicine 100% of the time. Do we reallybelieve that patients should differentiate thequality of hospitals based only on adherenceto the current process measures, which repre-sent a fraction of evidence-based care?

The researchers also point out that by mea-suringmortality, it is ultimately seen as a failure.Variation in hospital quality is multifactorialand has been attributed to a number of systemfailures, including not consistently followingthe evidence, operational deficiencies likeinconsistent care on nights and weekends, inap-propriate utilization, preventable patient safetyevents, gaps in care coordination, and genderand racial disparities.3e7 I believe that mostwould agree that deaths resulting from any ofthese circumstances would be seen as a failureof our health care system and warrant theneed for improvement strategies. Public report-ing of outcome measures has been shown to besuccessful in stimulating quality improvementinitiatives.8,9 In a 2009 quality report, theAgency for Healthcare Research10 found thatimprovements in acute inpatient care have out-paced any improvements in other aspects ofhealth care, such as prevention and outpatientcare. Certainly, hospitals have been the mostpublicly scrutinized aspect of health caredelivery in the last decade. I would, therefore,counter that measuring hospital mortality isa means to critically question the status quo. Ifwe do not question whether every mortality ispreventable we give up on the belief that wecan do better.

Another suggestion posed by the re-searchers is the possibility of limiting mortal-ity ratings to those high-risk procedures thatdo not overlap with end-of-life care forchronic conditions. I agree with the re-searchers that this is unlikely to happen butnot for the reasons stated as the lack ofexternal incentives. I would argue that exter-nal incentives are likely to increase the numberof measures, especially in the area of chronicconditions. The National Quality Forum hasrecently identified 20 high-impact conditions

in the Medicare population that account for95% of Medicare costs. These conditions in-clude chronic conditions such as heart failure,chronic obstructive pulmonary disease, stroke,and renal disease.11 Thus, additional outcomemeasures are likely in the foreseeable futurefor chronic conditions.

In light of the fact thatmortalitymeasures areunlikely to go away, Cassel et al. conclude thatthe methodology used by the Centers for Medi-care &Medicaid Services (CMS) is the standardto which the other entities should adhere. Intheir risk adjustment, CMS uses patient recordsfor up to 12 months before hospitalization.Additionally, CMS excludes any patient withhospice enrollment in the year before hospital-ization. Unfortunately, this level of data is onlyavailable to academic or not-for-profit organiza-tions. To protect patient privacy, the data madeavailable to commercial organizations do notcontain the necessary links to follow a patientover time. Even in this era of transparency, it isunfortunate that organizations such as Health-Grades do not have access to the same level ofdata that academics, not-for-profit organiza-tions, and CMS do.

Currently, given the data that we do haveaccess to, HealthGrades has opted to excludepatients with an encounter for palliative carein the diagnosis cohorts that we rate. As statedin the research, the International Classificationof Diseases, 9th Revision, Clinical Modification(ICD-9-CM) code V66.7, used to denote a pallia-tive consult, is typically used only in end-of-lifesituations. However, palliative care has beenshown to not only improve quality of life for pa-tients but also extend life.12 Palliative care ismost beneficial to patients and their familiesnot during their very last hospitalization butthroughout the continuum of their illness. Aspalliative care programs proliferate and pallia-tive care is no longer seen as end-of-life carebut evidence-based care and treatment, then itwill no longer be necessary or appropriate toexclude these patients but rather to includethem as part of the risk adjustment. Eitherway, the impact to the rating is not ‘‘punitive’’because the patient is not counted or it in-creases the expected mortality rate. So, I wouldadvise health care administrators that if pallia-tive care is the right thing to do for the patient,then it is the right thing to do for your publiclyreported ratings.

930 Vol. 40 No. 6 December 2010Commentaries

Disclosures and AcknowledgmentsThe author was not supported by grants or

other financial support for this article, andshe declares no conflicts of interest.

doi:10.1016/j.jpainsymman.2010.09.010

Address correspondence to: J. Brian Cassel, PhD, VirginiaCommonwealth University Massey Cancer Center,401 College Street, P.O. Box 980037, Richmond, VA23298-0037, USA. E-mail: jbcassel@vcu.edu

Accepted for publication: September 30, 2010.

References1. Lilford R, Pronovost P. Using hospital mortalityrates to judge hospital performance: a bad idea thatjust won’t go away. BMJ 2010;340:c2016.

2. Fonarow GC, Abraham WT, Albert NM, et al. As-sociation between performance and clinical out-comes for patients hospitalized with heart failure.JAMA 2007;297:61e67.

3. Horwich TB, Hernandez AF, Liang L, et al. GetWith Guidelines Steering Committee and Hospi-tals. Weekend hospital admission and dischargefor heart failure: association with quality of careand clinical outcomes. Am Heart J 2009;158:451e458.

4. Reeves MJ, Smith E, Fonarow G, et al. GWTG-Stroke Steering Committee & Investigators. Off-hour admission and in-hospital stroke case fatalityin get with the guidelines stroke program. Stroke2009;40:569e576.

5. Schwamm LH, Reeves MJ, Pan W, et al. Race/ethnicity, quality of care, and outcomes in ischemicstroke. Circulation 2010;121:1492e1501.

6. LeapeLL, BrennanTA, LairdN, et al. Thenatureof adverse events in hospitalized patients. Results ofthe Harvard Medical Practice Study II. N Engl J Med1991;324:377e384.

7. The Commonwealth Fund Commission ona High Performance Health System. Why not thebest? Results from a national scorecard onU.S. healthsystem performance. 2008. Available from http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2008/Jul/Why-Not-the-BesteResults-from-the-National-Scorecard-on-U-SeHealth-System-Performancee2008.aspx. Accessed September 3,2010.

8. Hibbard JH, Stockard J, Tusler M. Does publiciz-ing hospital performance stimulate quality improve-ment efforts? Health Aff (Millwood) 2003;22:84e94.

9. Lindenauer PK, Remus D, Roman S, et al.Public reporting and pay for performance inquality improvement. N Engl J Med 2007;356:486e496.

10. Agency for Healthcare Research and Quality.2009 AHRQ quality report. 2010. Available fromhttp://www.ahrq.gov/qual/nhqr09/nhqr09.pdf. Ac-cessed August 27, 2010.

11. National Quality Forum. Prioritization of high-impact conditions and measure gaps final report.2010. Available from http://healthcaredisclosure.

org/docs/files/CMSQualityMeasurementRoadmap.pdf. Accessed September 8, 2010.

12. Temel JS, Greer JA,Muzikansky A, et al. Early pal-liative care for patients with metastatic non-small celllung cancer. N Engl J Med 2010;363:733e742.

Response toCommentariesJ. Brian Cassel, PhDVirginia Commonwealth University Massey Cancer Center,

Richmond, Virginia, USA

We came here neither to bury hospital mor-tality rates nor to praise them but to clarifyand publicize the methods used to generatethem and to suggest ways to improve them.Shortly after we started this project, we real-ized how little dialogue there was betweenthe various entities computing mortality ratesand the palliative care community. We appreci-ate Ms. Reed and Dr. Olmsted et al. participat-ing, through their commentaries, ina dialogue with the palliative care communityon this topic. Getting their perspective is animportant step toward mutual understandingabout the measurement of hospital mortalityas a marker of hospital quality and to what ex-tent end-of-life care is and should be takeninto account.Goals of care are not yet adequately in-

corporated into hospital mortality statistics.There are a number of steps the palliativecare community can take to improve the cur-rent situation, including but not limited tothe following:

1) Advocate for Medicare to improve thedata available to all entities to enablethem to incorporate goals of care moreadequately. This may include expandingaccess to identified (rather than de-identified) data, or at the least adding